SIMPLE APPROACH TO

PERIOPERATIVE HYPERTENSION
Paskariatne Probo Dewi
 Background
• Hypertension occuring in the pre-, intra-, or
postoperative period
– Previous history of HTN (most common)
– Acutely during the perioperative period (anxiety,
pain, changes in intravascular volume, stress-
induced SNS activation)
 Background
• HTN is the most frequent preoperative
abnormality in surgical patients, with an
overall prevalence of 20-25%

• Preexisting HTN is the most common

medical reason for postponing surgery

Athanasios et al. ESH Update on Hypertension Management, 2011

 Everyday questions
• Should I go ahead with a patient with uncontrolled
HTN, or should I postpone the surgery?
• Are patients with uncontrolled HTN at an increased
Minimal risk
perioperative dataforregarding perioperative
cardiovascular complications?
• What is therisks associated
risk of with HTN during and
cardiac complications
after surgery?
• How can that risk be reduced or eliminated?
• Are there any data on which I can base my decision?
 CV risk during a non-cardiac surgery :
Pathophysiology

Tissue injury Fluid shifts Alteration in balance

between prothrombotic
and fibrinolytic factors

• Tachycardia
• Hypertension Atherosclerotic
Or plaque rupture Hypercoagulability
• Hypotension

Increased myocardial
oxygen demand
Myocardial
ischemia/ACS
BP changes in perioperative period
 BP response during anesthesia
• Sympathetic activation during anesthesia
induction an cause BP to rise by 20-30
mmHg, and HR to increase by 15-20 bpm in
normotensive individuals

• May be more pronounced in pts with

untreated HT  SBP can increase by 90
mmHg and HR by 40 bpm
Wolfsthal, SD Med Clin North Am 1993; 77 : 349
• As the period of anesthesia progresses, patients
with preexisting HTN are more likely to experience
intraoperative lability (either hypotension or
hypertension), which may lead to myocardial
ischemia

• There is no evidence of superiority of any specific

anesthetic agents in non-cardiac surgery

Wolfsthal, SD Med Clin North Am 1993; 77 : 349

 Effects of perioperative HT
• CVS effects:
– Increased BP→ ↑ afterload & myocardial oxygen
demand → myocardial oxygen supply and demand
imbalance.

– Chronic ↑ BP → myocardial hypertrophy → myocardial

oxygen supply and demand imbalance

– Hypertrophied myocardium → decreased compliance →

abnormal diastolic filling

– Diastolic dysfunction especially apparent during stress,

important during surgery and acute recovery interval
Athanasios et al. ESH Update on Hypertension Management, 2011
• CNS effects:
– Increased risk of stroke
– Impaired cerebral autoregulation
– Especially important in neurosurgical patients

• Effects on renal function

– Effective control of BP prevents renal
dysfunction
– Intraoperative urine output monitoring for
assessment of perioperative renal function
Athanasios et al. ESH Update on Hypertension Management, 2011
 Case illustration
• Male, 64 yo.
• Smoker, dyslipidemic and hypertensive with a history of
paroxysmal AF admitted for elective prostatectomy

• In the preoperative evaluation :

– Clinic BP 160/85 mmHg, HR 85 bpm
– No cardiac murmurs, no peripheral edema
– Asymptomatic for cardiac symptoms (no angina)
– Basic lab test : within normal values
– Recent echo : no LVH, EF 60%, mild dilatation of LA
– Under daily treatment with Bisoprolol 5 mg, Atorvastatin 20
mg, Aspirin 100 mg, and a fixed combination of
Irbesartan/HCT 300/12.5 mg
Case illustration
 Preoperative evaluation of hypertensive patient :
Question to be answered

• What are the determinants of cardiac risk in a non

cardiac surgery? Is HTN a risk factor for CV events
in a non cardiac surgery?
• Should we postpone the surgery in order to control
the BP?
• What additional test may be needed?
• Which is the appropriate pharmacotherapy before,
during and after surgery?
Risk for CV events in non cardiac surgery
1. Type of surgery
– Low risk
– Intermediate risk
– High risk

2. Setting of surgery
– Emergent
– Urgent
– Elective

3. Comorbidities
Type of surgery and estimated 30 day
cardiac events rates
 Comorbidities and cardiac risk
Lee’s Revised Cardiac Risk Index (RCRI)

Hypertension is not included

 ACC/AHA Clinical Predictors of Increased
Perioperative CV Risk (MCI, HF, Death)

MINOR INTERMEDIATE MAJOR

• Advanced age • Mild angina pectoris • Unstable coronary
• Rhythm other than • Prior MCI syndromes
sinus • Compensated or • Decompensated HF
• Abnormal ECG prior HF • Significant
• Low functional • Diabetes mellitus arrhythmia
capacity • Chronic kidney • Severe valvular
• History of stroke disease heart disease
• Uncontrolled
systemic HT
(>180/110 mmHg)
 Preoperative evaluation of hypertensive patient :
Question to be answered

• What are the determinants of cardiac risk in a non

cardiac surgery? Is HTN a risk factor for CV events
in a non cardiac surgery?
• Should we postpone the surgery in order to control
the BP?
• What additional test may be needed?
• Which is the appropriate pharmacotherapy before,
during and after surgery?
 Level of BP and Preoperative evaluation

• Pts with well-controlled HTN are less likely to experience

intraoperative BP lability and postoperative complications
than pts with poorly controlled HTN
• The ideal circumstances is to normalize BP for several
months prior to elective surgery
• In pts with HTN grade I-II, there is no evidence that delay in
surgery in order to optimize therapy is beneficial
• Patients with newly diagnosed mild hypertension, treatment
may be delayed till after surgery.

Kristensen et al. ESC Guidelines on non cardiac surgery , 2014

Level of BP and Preoperative evaluation
• In pts with HTN gr III (BP >180/110 mmHg) the
potential benefits of delay surgery to optimize the
pharmacological treatment should be weighted against
the risk of delaying the surgical procedure

• More prone to perioperative ischemia, arrhythmias and

cardiovascular lability, but no clear cut difference that
deferring and anesthesia decreases perioperative risk.

• In case of urgent surgery, the pts should be treated

with a parenteral drug acutely
Kristensen et al. ESC Guidelines on non cardiac surgery , 2014
 Preoperative evaluation of hypertensive patient :
Question to be answered

• What are the determinants of cardiac risk in a non

cardiac surgery? Is HTN a risk factor for CV events
in a non cardiac surgery?
• Should we postpone the surgery in order to control
the BP?
• What additional test may be needed?
• Which is the appropriate pharmacotherapy before,
during and after surgery?
 Specific issues to be addressed in
hypertensives
• History
• Physical examination
• Laboratory examination
• ECG
 History
• Family history for atherosclerotic CV disease
• Clinical history
– Other risk factors (dyslipidemia, smoking,
obesity, DM)
– Dietary habits/sleep disorders
– Previous and current treatment
– Symptoms related to secondary HTN, CAD, CHF,
stroke, PAD
Assessment of functional capacity

Kristensen et al. ESC Guidelines on non cardiac surgery , 2014

 ECG
• Should be part of all routine assessment of
subjects with high BP in order to detect LVH,
pattern of strain, ischemia and arrhythmias

• Presence of Q waves or significant ST segment

elevation or depression have been associated with
increased incidence of preoperative cardiac
complications

Athanasios et al. ESH Update on Hypertension Management, 2011

 Echocardiogtaphy

• Echocardiography is recommended when a more sensitive

method of detection of LVH is considered useful as well as
assessment of LV systolic function
 Stress test perioperatively
What information do we get?
• Stress test : very high predictive value (90-
100%) but low predictive value (30-67%)

• Stress test is more useful for reducing

estimated risk if negative, than for
identifying patients at very high risk when
positive

Poldermans al. ESC Guidelines on non cardiac surgery , 2009

 Preoperative evaluation of a
hypertensive patient

Safety of the patient Deferments/cancellatio

perioperatively n of surgery

• Identify undiagnosed or uncontrolled HTN

• Estimate the true high level of BP

In order to reduce
– The operative risk in the short term period
– Adverse long term effects
 Preoperative evaluation of hypertensive patient :
Question to be answered

• What are the determinants of cardiac risk in a non

cardiac surgery? Is HTN a risk factor for CV events
in a non cardiac surgery?
• Should we postpone the surgery in order to control
the BP?
• What additional test may be needed?
• Which is the appropriate pharmacotherapy before,
during and after surgery?
 Pharmacotherapy
• ACC/AHA advocate treating stage 3 hypertension (BP
> 180/110 mmHg) before surgery

• If surgery is urgently needed, control of BP can be

achieved over minutes to hours with the
administration of intravenous agents

• Patient who are taking chronic antihypertensive

treatment should be continue taking their
medications until the time of surgery
Fleisher et al. ACC Guidelines on non cardiac surgery , 2014
 Case illustration
• Male, 64 yo.
• Smoker, dyslipidemic and hypertensive with a history
of paroxysmal AF admitted for elective prostatectomy
• In the preoperative evaluation :
– Clinic BP 160/85 mmHg, HR 85 bpm
– No cardiac murmurs, no peripheral edema
– Asymptomatic for cardiac symptoms (no angina)
– Basic lab test : within normal values
– Recent echo : no LVH, EF 60%, mild dilatation of LA
– Under daily treatment with Bisoprolol 5 mg, Atorvastatin
20 mg, Aspirin 100 mg, and a fixed combination of
Irbesartan/HCT 300/12.5 mg
Recommendation of B-blockers
 Recommendation of ACE inhibitor

• Transient discontinuation (24h before surgery) of ACEIs

or ARBs before non-cardiac surgery in hypertensive
patients should be considered.

• Resume after patient’s endovascular volume has been

stabilized

• When ACEI/ARB are prescribed for HF their

discontinuation at the preoperative phase should be
examined more carefully

Kristensen et al. ESC Guidelines on non cardiac surgery , 2014

 Calcium channel blockers

• Calcium channel blockers (diltiazem)

significantly reduced ischemia and
supraventricular tachycardia

• The use of short acting dihydropiridine

(nifedipine) should be avoided

Kristensen et al. ESC Guidelines on non cardiac surgery , 2014

 Diuretics
• Diuretics for hypertension should be continued to
the day of surgery and resumed orally when
possible.

• If BP reduction is required before oral therapy can

be continued, other antihypertensive agents may
be considered.

• Careful attention must be paid to the potassium

level in patients on diuretics.
Kristensen et al. ESC Guidelines on non cardiac surgery , 2014
 Alpha 2 receptor agonists
• Clonidine increased the risk of clinically
important hypotension and non-fatal cardiac
arrest

• Therefore, alpha2 receptor agonists should

not be administered to patients undergoing
non-cardiac surgery.

Kristensen et al. ESC Guidelines on non cardiac surgery , 2014

Kristensen et al. ESC Guidelines on non cardiac surgery , 2014
Recommendation for the preoperative evaluation of HT pts
 In our case
• He was advised to
• Postpone Aspirin (5 days prior) and the fixed
combination of Irbesartan/HCT (1 day prior)
• Proceed with Bisoprolol and Atorvastatin
• Evaluate initiation of Irbesartan/HCT when
volume balanced, and aspirin when bleeding
risk is diminished (3rd and 7th day respectively)
• Re-evaluate after 4 weeks for BP < 140/90
mmHg and further assessment of target organ
damage
 Take home messages
• HTN is a very common preoperative abnormality in
surgical patients and is accompanied by multiple
other CV risk factors
• Little clinical trial evidence is available to guide
therapy of HTN in the perioperative period
• The extent of diagnostic approach beyond history,
physical examination, laboratory evaluation and ECG
depends on :
– The urgent of surgery and surgery-specific risk
– The presence of active cardiac condition and other risk
factors
– The functional capacity of the patient
 Take home messages

• Continuing chronic BP medications until

surgery and reestablishing a good regimen
postoperatively are key strategies to
preventing perioperative hypertension and
its potential complications.